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May 21, 2019

A pregnant pause

By Caitlin Doran

In many states, women can expect pregnancy to restrict their advance directives.

Search online for what
to do when getting ready for baby and you’ll find endless checklists of
essentials every parent needs, from onesies and diapers to high tech strollers
and baby monitors. The best lists also mention an important legal document that
expectant parents should consider completing before baby arrives: an advance
directive outlining the mother’s health care wishes should she become
unable to make decisions or speak for herself.

However, according to a report recently published by researchers
at Mayo Clinic and other institutions
in the Journal of the American
Medical Association (JAMA), what expectant parents often don’t realize – and
what isn’t disclosed, even on most advance directive forms—is that the majority
of U.S. states have laws on the books that restrict or invalidate a pregnant
woman’s advance directive.

These states put a “pause” on these patients’ ability to
control their health care. And they often do not communicate this fact this to
patients, who fill out these forms in good faith.

Erin DeMartino, M.D.

The purpose of advance directives

Life can change in an instant, and even young adults can face a serious medical condition. “When you become pregnant, that’s a good time to start looking ahead and thinking about an advance directive,“ says Erin DeMartino, M.D., a pulmonary and critical care physician at Mayo Clinic’s campus in Rochester and first author of the report published in JAMA.

Advance directives safeguard patient autonomy and control
over life-and-death medical decisions that are difficult to foresee. They allow
a patient to name a person who can make health care decisions on their behalf.
They also give a patient the opportunity to state specific medical treatments
they do or do not want.

“It’s ironic, “says Dr. DeMartino, “that when young women are
faced with perhaps their first major medical situation—pregnancy and childbirth—their
control of their own health destiny is often taken away by the State. And
because this fact is usually not communicated on the official state advance
directive documents, patients might not even know it.”

The ethical way forward requires increased transparency

Laws governing life-and-death decisions for pregnant mothers
vary widely state-by-state. According to the report published in JAMA, 38
states have laws that identify pregnancy as a condition that affects decisions
for incapacitated women. 30 of these states restrict a woman’s or her
surrogate’s choice regarding withholding or withdrawing life-sustaining
treatment and 25 states invalidate a woman’s advance directive. Only 11 states disclose those restrictions on
their advance directive documents.

In this situation, transparency is essential, says
Richard Sharp, Ph.D., director of the
Mayo Clinic Biomedical Ethics Research Program. Patients should always be
informed about potential situations that might prompt an advance directive to
be restricted or temporarily revoked. “These important details should be
spelled out in the forms that patients sign and in the educational materials
that are often distributed to patients when they sign an advance directive,”
says Dr. Sharp.

“It’s of fundamental importance that women understand what
they’re signing, “agrees Dr. DeMartino. “If you’re using an advance directive,
there should be no surprises when it comes to making your health care wishes
known or in determining if those wishes will be carried out.”